Methodological approach

I adopted a qualitative approach to address the research questions posed in this thesis. A key strength of qualitative approaches is that they can provide rich and vivid accounts of an issue of interest, set within a clearly defined real-world context (Miles and Huberman, 1994, Snape and Spencer, 2009). It is therefore well suited to exploring complex processes such as decision making (Maxwell, 2005, Ritchie, 2009, Snape and Spencer, 2009). In the context of this research, adopting a qualitative approach also enabled me to explore the taken for granted knowledge and assumptions that underpinned the decision making processes in the four MDTs under study (Tracy, 2010). This is in contrast to quantitative methods where the focus is often on causation or the correlation between factors of interest (Maxwell, 2005).

65 There are many different methodological approaches within the framework of qualitative research (Murphy, 2001, Carter and Little, 2007, Snape and Spencer, 2009). The approaches used by health services researchers are often influenced by methodologies well-established in the social sciences, for example from sociology, anthropology and psychology (e.g. grounded theory, ethnography and

phenomenology) (Thorne, 2011). These methodological approaches incorporate a range of beliefs about the nature of reality and what we can know about the social world, as well as the nature of knowledge and how we can acquire it (Ritchie, 2009, Snape and Spencer, 2009). They also shape the way in which research should be conducted, from the development of research questions to data collection, analysis and dissemination of the findings (Thorne, 1991).

However, there can be tensions between the applied nature of health services research, and these traditional qualitative methodologies. While many of the latter prioritise the development of theory, in the field of health services research,

findings must add practical value in the context of complex clinical settings (Thorne, 1991, Thorne, 2008, Thorne, 2011).

As a result a number of researchers in applied fields have advocated the use of generic qualitative research (Neergaard et al., 2009, Ritchie, 2009, Kahlke, 2014).

This is research that “has not been guided by an explicit or established set of

philosophic assumptions in the form of one of the known qualitative methodologies”

(Caelli et al., 2003) (p.4). Instead, generic qualitative research modifies aspects of a single established methodological approach, or integrates a series of tools and techniques from more than one (Kahlke, 2014). As described below, I adopted the latter approach, using tools and techniques that best helped me to address the research questions posed in this study.

5.1.1 Rationale for adopting a generic qualitative approach

Moving away from a reliance on a single traditional methodology is not an entirely new approach in qualitative research (Caelli et al., 2003), and has been used by

66 other health service researchers, for example in a study exploring collaboration in unscheduled emergency care (Cooper et al., 2007). The key benefit relates to the ability to prioritise real-world clinical issues, and to make decisions about methods on the basis of what works. This can help to avoid a preoccupation with

methodology at the expense of the substance of the research, or ‘methodolatry’

(Chamberlain, 2000, Ritchie, 2009, Thorne, 2011).

In addition to these benefits, a generic approach was particularly suitable for this study because my research questions were developed after data collection

(reflecting the timescales of the NIHR-funded MDT Study). Using data collected for one purpose to address a different set of research questions can result in poor methodological fit (Edmondson and McManus, 2007). This would have been

particularly problematic if I had tried to apply a traditional qualitative methodology

‘post hoc’ to data collected as part of a mixed methods study. Instead, adopting a generic approach enabled me to develop research questions that capitalised on the data that had already been collected, and to build on the earlier mixed methods analysis (Raine et al., 2014a). To ensure congruence between methodology and methods I made a series of iterative decisions about which data to use from the MDT Study dataset, and how to analyse these. I also constantly reviewed whether the new questions I wanted to pose could be appropriately answered by the data I had.

5.1.2 Rationale for data collection methods

Within this framework, I used qualitative data collected from non-participant observation and semi-structured interviews with MDT professionals and patients to address the research questions posed in this thesis. Non-participant observation was an appropriate method in this context because it generated data that enabled me to explore the decision making process in detail in a naturalistic setting (Savage, 2000). Importantly, it also allowed me to consider the largely unarticulated and taken for granted dimensions of behaviour in these four teams by reflecting on who did or did not participate, as well as reflecting on what was and was not being said

67 (Tracy, 2010). In turn, the semi-structured approach used during the interviews provided me with rich data about participants’ perspectives of the meetings, and the views of patients (Bloomberg and Volpe, 2012). Combining these approaches enabled me to contrast and compare what happened in practice with what was said in interviews (Savage, 2000).

Observation and interview methods have been used by other health service researchers who have studied MDT meetings (Lanceley et al., 2008, Kidger et al., 2009, Frykholm and Groth, 2011), as well as by organisational behaviour scholars to study status in real-world settings (Nembhard and Edmondson, 2006, Rivera, 2010).

Although the patient perspective has less frequently been included in studies of MDT meetings, a small number of researchers have recently begun to consider this too (Lamb et al., 2014b, Taylor et al., 2014).

One of the benefits of combining these different methods within my study is that it enabled me to gain an understanding of MDT meetings from different perspectives (Barbour, 2001). The purpose of this was not to establish a more ‘accurate’

representation of MDT meetings, but to explore complementary perspectives in order to broaden and deepen understanding of the decision making process (Barbour, 2001).

5.1.3 Philosophical approach

This approach to combining methods reflects the critical realist philosophy that underpinned my methodological approach. Critical realism acknowledges the existence of a social world independent of individual understanding. However, it also recognises that different actors will create different interpretations of this reality (combining a realist ontology with a constructivist epistemology) (Maxwell, 2012). Research conducted from this philosophical position is therefore less

concerned with determining whether participants’ perspectives are valid than with a desire to understand meaning from their perspective (Thorne, 2000).

68